Acute Inpatient Rehabilitation Care for a Patient Learning to Use an AKA Prosthesis: Amputee Case Study

Title[edit | edit source]

Acute Inpatient Rehabilitation Care for a Patient Learning to Use an above knee amputation (AKA) Prosthesis: Amputee Case Study

Abstract[edit | edit source]

The patient is a 68 yr old woman admitted to acute rehabilitation for dynamic alignment and prosthetic training with her new AKA prosthesis. The patient has a complex medical history but was motivated to increase her independence with the prosthesis. The patient lives alone so her primary goals were to be safe and independent using the prosthesis for mobility in her home environment and to have the knowledge she needs to safely use her prosthesis. The patient was very clear she would only stay for 4-5 days at rehabilitation so physical therapy (PT) treatment focused on education, dynamic alignment and prosthetics training to accommodate patient goals

Key Words[edit | edit source]

transfemoral, inpatient rehabilitation, mutlidisplinary team, prosthetic exercises, International Classification of Functioning, Disability and Health (ICF) model, patient education

Client Characteristics[edit | edit source]

The patient is a 68-year-old female who had surgery for a Left above knee amputation in May 2015 due to gangrene in left lower extremity (LLE). She was admitted to acute rehabilitation after her surgery for the amputation. She did well and left at primarily a wheelchair level with limited ambulation in the home with the rolling walker (RW). The patient was staying on 1 level in her home and did not need to navigate stairs. She received her prosthesis on 6/19/15 and was seen for OP-PT follow up on 6/22/15. The patient was having difficulty managing and donning/doffing her prosthesis independently. She lives alone so it was thought she would benefit from a direct admit to acute rehabilitation for further education and training. She was admitted to acute rehabilitation on 6/22/15 for dynamic alignment and prosthetic training.


The patient has a significant past medical history for: Peripheral vascular disease (PVD) with multiple vascular surgeries and grafts, hypertention (HTN), claudication, chronic obstructive pulmonary disease (COPD), dyspnea, right shoulder dislocation, scleroderma, pulmonary infiltrates, psoriasis and gastroesophageal reflux disease (GERD). The patient is currently a smoker, despite education and assistance available for cessation, patient declines.

The patient lives alone in a multi level home. He has 1 step to enter her home and 1 stepped/slanted step into her kitchen. She uses the wheelchair in the kitchen and is ambulatory with the rw, limited distances in the home. She is only using only one level in her home. The patient has intermittent assist available from friends. The patient is retired. She enjoys spending time with her 11 yr old foster son.

The patient is very independent and seeks to regain increased independence and function with the prosthesis. The patient wants to pursue follow up outpatient physical therapy OP-PT.

Examination Findings[edit | edit source]

Patient goals: ambulate and negotiate steps independently with prosthesis, ambulate to/from the car with her prosthesis and perform ambulatory activities with her foster son.

Findings:

  • Occasional phantom sensation/pain.
  • Patient is motivated/great follow through.
  • Decreased activity tolerance/dyspnea.
  • Well healed skin and AKA site.
  • Shrinker for management of AKA swelling.
  • Bilateral upper limb extremity (BUE) and bilateral lower limb (BLE) range of movement (ROM): within normal limits (wnl) B hip extension: 10 degrees Strength: B hip flexion,extension, abd/add: 4/5 R knee 4/5 R ankle: 5/5
sensation intact
  • BLE balance: stand close supervision with rw/prosthesis
independent with wc mobility using BUE/right lower extremity (RLE).
  • Transfers: stand step with rw, prosthesis, close supervision
  • Gait: patient ambulating with rw, prosthesis, 30 ft with close supervision, decreased gait speed, decreased step length, intermittent left knee instability and decreased step width. Equipment: check socket, gel liner suspension, safety knee, college park foot and no socks

ICF:

  • Pathology: Left above knee amputation/significant past medical history (PMH)
  • Body Function structure: decreased lower extremity (LE) strength, functional balance, activity tolerance, skin integrity with prosthetic use and gait impairments.
  • Activity limitations: assist with don/doff of prosthesis/management, assist of 1 with transfers/gait with prosthesis. Unable to negotiate steps/outside surfaces with prosthesis.
  • Participation: unable to ambulate to car or in the community or perform activities in standing/walking with foster

Clinical Hypothesis[edit | edit source]

Anticipate that patient will make nice progress given her motivation, excellent carry over/follow through with education, current mobility status, good general strength, ROM with no contractures, at this time limited limb/phantom pain and no issues with skin integrity. The patient's size is also an asset to her overall mobility. Barriers to pt progress could be pt's significant PMH for COPD, dyspnea and current smoking, which could limit activity tolerance. Significant PVD will also need to be monitored for claudication in RLE. HTN will require close monitor given increased cardiovascular demands placed on pt with AKA prosthetic training. The patient will also put increased demands on BUE with rw training and pt has a history of right shoulder dislocation which will need to be monitored for over use. The patient does live alone so she will need to be independent with all prosthetic management/education and mobility in the home with the prosthesis.


Expect pt to reach goals of independent: don/doff of prosthesis, increase prosthetic wear time 4-6 hours a day, independent with skin inspection, independent knowing when to add socks and contact prosthetist, independent with home program, independent transfer and ambulating with prosthesis/rw in the home environment.

Discussed that due to patient's short length of stay her goals related to independent stair negotiation, walking to car and progression with walking activities with foster son, she would have to defer these goals to OP-PT. Patient in agreement.

Intervention[edit | edit source]

Due to short rehabilitation stay of 4 days treatment was very focused. Our prosthetist was available 3 of the 4 days for collaboration with the physical therapist, physical therapy assistant and physiatrist regarding alignment and prosthetic fit. Adjusting prosthetic length to accommodate length discrepancy and rotated socket mildly into external rotation (ER) to decrease internal rotation (IR). Collaboration occurred with nursing and occupational therapist (OT) regarding wear time of the prosthesis, skin inspection and progression with functional mobility using the prosthesis. Social work was involved regarding discharge planning (dc) planning, transportation home and OP-PT. Contacted OP-PT to discuss pt status/issues. Education provided regarding: independent don/doff of the prosthesis, so pt could use it at home. Need for frequent skin inspection with gradual increase in wear time of prosthesis. Patient using mirror to inspect posterior thigh on her own. Adding: stockings to prosthesis for proper fit and when to stop wearing the prosthesis. Transfer training with the rw/prosthesis from various surfaces and heights. Gait training was initiated initially in the parallel bars, progressing quickly to the rw/prosthesis on level and uneven surfaces (ramps/side walk/carpet/inclines)
Standing balance and weight shift activities to facilitate LLE weight bearing: with single and no UE support, ball toss, reaching outside base of support for objects left and right and across body.
standing exercises: with light UE support: hip flexion, extension, abduction/adduction, 10 repetitions to BLE to facilitate LLE strength and weight shift.

Outcome[edit | edit source]

  • Patient was independent with don/doff of the prosthesis. She was independent determining when to add socks and when to call prosthetist.
She was tolerating prosthetic wear time for 1-2 hours, 3 times a day.
  • Independent with skin inspection. Independent with transfers and ambulation in the room with the rw and prosthesis.
  • Patient was independent with her home program.
  • Goals not reached due to short length of stay. Patient decline longer stay to achieve these goals. She wanted to address them on an OP-PT basis.
  • She required supervision with outdoor ambulation and was unable to progress to trial with curbs or stairs due to short length of stay.
  • The last day of treatment pt had increased pain over the distal/anterior transfemoral surface, there was no redness or bruising but it was painful with wear time and mobility.
  • Discussed with patient that she should take a break from wearing the prosthesis for 2 days at home and resume again gradual wear time on Monday. Skilled discussion regarding risk of bruising and skin break down. She would need to monitor this closely and work with her OP-PT to assist with activity progression.

Discussion[edit | edit source]

Since initiating this course I have a new prospective on some of the education and treatments that I would provide. I need to spend more time focusing on the education: regarding the need for physical activity/exercise, protection and inspection of the non-involved limb, diet, smoking and prosthetic care. I realize how important these aspects of care are on the patient's wellbeing and success.[1]

I also realized that I did not initiate any outcome measures, which I am now more aware of. This would be helpful in monitoring pt progress and progression with the use of the prosthesis. There are simple things I could have done that are not time consuming like gait speed, 6 min walk or Timed Up and Go Test (TUG). I am now aware of Outcome measures available specifically to patient's who have had amputations and will now reference this with my current pt's and use as appropriate to monitor baseline progress.[2]

This course also provided an increased awareness to the stages of grieving that patient's go through and the support that they need. I would love to see a support group develop at our site to support these patient's going through amputations. Peer support would be wonderful for these patients.[3] I also have an increased awareness to exercises and activities from post amputation to exercise with the prosthesis.[4]

I have an increased awareness to the ICF model.[5]

References[edit | edit source]

  1. Pantera, E,Pourtieer-Piotte, C. Bensoussan, L.,Coudeyre,E. (2014). Patient education after amupation: systematic review and experts opinions. Annuals of physical and rehabilative medicine, 57(3) 143-158. From the course work: Discharge Management of the Amputee
  2. (2014)British Association of Chartered Physiotherapists in Amputee Rehabilitatin (BACPAR) Outcome Meaures Toolbox
  3. WHO textbook Chap 2.3 (pages 19-21)
  4. Gaily book Prosthetic Gait Training Program for Lower Extremity Amputees
  5. CF model from pre-course work